Over one-in-ten U.S. households are food insecure. That is, these
households include members who do not always have access to enough food
for active, healthy living because their household lacks money or other
resources for food. Children (18.2%) are far more likely than adults
(10.8%) to be in households suffering from food insecurity (Nord,
Andrews & Carlson, 2005). At the same time, approximately 46 million
Americans, or 16% of the population, are without health insurance
(DeNavas-Walt, Proctor & Lee, 2006). Research suggests that spells
without insurance are usually relatively short in duration, but can be
relatively frequent (Nelson, 2003). Children are most likely to
experience repeated spells without health insurance, whereas adults age
55-64 experience the most frequent insurance coverage transitions. In
addition, health care costs continue to increase both in nominal amount
and as a share of household expenditures (U.S. Bureau of Labor
Statistics, 2007). One of the largest components of out of pocket
medical expenditures, prescription drugs, is driving much of the
increase in out of pocket expenditures (Kaiser Family Foundation, 2006;
U.S. Bureau of Labor Statistics, 2007). Despite an extensive network of
private and public food assistance programs and public health insurance
options, these statistics demonstrate that it is difficult for millions
of families to meet these basic needs. There is some evidence that
family resource allocation decisions involve tradeoffs between basic
needs (Long 2003; Sharpe, Fan & Hong, 2001), but there is little
research that moves beyond cross-sectional estimates to examine
family-level economic outcomes associated with the acquisition of food
and medical care over time.

Data and Analyses

This study of the relationship between health insurance, medical
expenditures and food insecurity examined panel data from the 2001
Survey of Income and Program Participation (SIPP). The SIPP is a
nationally representative survey of the non-institutionalized United
States population conducted by the U.S. Census Bureau. The three-year
2001 panel collects a "core" set of questions that are
collected from respondents every four months. The SIPP also consists of
"topical" modules for questions that are not asked each wave.
The timing and frequency of the topical modules varies, as does the
duration of the reference period to which the questions refer. The data
used here were collected from January, 2003 to December, 2003 (waves 7,
8, and 9) and, depending on the rotation group of the respondent, refer
to a continuous 12 months that began as early as October 2002 and ended
as late as December, 2003. It was from this 12-month period that health
insurance status, employment, sociodemographic information, and family
composition data were drawn. The analytic sample included 49,989 people
age 0 to 87 who were members of 16,236 families in 2003. When weighted,
this sample represented 170.3 million people who were members of 70.8
million families.

The multivariate analyses focused on the relationship between food
insecurity and medical out of pocket expenditures while explicitly
controlling for the potential endogeneity of the two variables.
Specifically, a two stage probit least squares estimation (2SPLS) that
simultaneously fit the probit and least squares equations was used. This
approach allowed us to account for the joint decision making made by
households about food and medical expenditures. A 2SPLS estimation,
rather than single-equation estimation methods, allowed food insecurity
status to be included among the explanatory variables in the medical out
of pocket expenditure equation, and medical out of pocket expenditures
to help explain food insecurity.

Results and Discussion

The results from this nationally-representative sample of families
found no evidence that food and medical expenditures crowd out one
another. That is, when considering the economic circumstances of
families, there was little evidence that food and medical expenditures
were an either/or decision for families. Rather, as families'
medical out of pocket expenditures decreased, they were more likely to
experience food insecurity. Similarly, as medical out of pocket
expenditures increased, families' risk of food insecurity lessened.

A secondary research question addressed how varying health
insurance coverage across family members and over time (e.g., everyone
was continuously-insured over the study period, at least one member was
uninsured at some point in time) was associated with a medical out of
pocket expenditures. The results indicated that families with a higher
percentage of family members covered by health insurance also had higher
medical out of pocket expenditures. Similarly, families with a lower
percentage of family members covered by health insurance had lower
medical out of pocket expenditures.

A final research question addressed how varying health insurance
coverage across family members and over time (e.g., everyone was
continuously-insured over the study period, at least one member was
uninsured at some point in time) was associated with families' food
insecurity status. The results indicated that the likelihood of all
family members being uninsured for all 12 months was more than double
for food insecure families (3.9%) compared to food secure families
(1.9%). Similarly, the percentage of food insecure families with at
least one family member uninsured at some point during the study period
was more than double that of food secure families (58.7% versus 28.2%).

Several strengths of this research are worth noting. First, the use
of families as the unit of analysis recognizes that food allocation,
insurance procurement, and medical expenditure decisions do not
typically take place at the individual level. Families generally pool
resources and allocate these resources to maximize the wellbeing of its
members. Second, the simultaneous estimation of food insecurity and
medical care expenditures provides greater confidence about the nature
of the relationship than single-stage estimations. Finally, our
consideration of the relationship between family-level food insecurity
and medical care expenditures, over a one-year period, using
nationally-representative data, is an advancement over individual-level,
cross sectional analyses.

The results of this research are contrary to findings from smaller
studies that suggest that individuals and families make choices between
food and medical care or services (Biros, Hoffman, & Resch, 2005;
Kersey et al., 1999). Because the literature is not clear on the
relationship between expenditures on food and medical care, future
research will investigate the unique economic situations of those who
have low incomes. Similarly, although seniors residing in families are
included in this research, seniors who live alone and/or not with a
family are excluded. An extension of this work will include separate
analyses of senior families and senior households to investigate the
unique challenges faced by the elderly, especially the elderly who are
in poverty or who have low incomes.

The results of this research suggest that programs that seek to
help families to obtain food or health care actually may be generating
benefits beyond meeting that specific need if one considers
cross-program gains. When resources available for one basic need, such
as food, are increased, resources for other basic needs are more readily
available. As policymakers and program administrators continue to devise
ways to help families meet their needs, they should consider the
overlapping benefits of food assistance and health insurance programs.